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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610091
Report Date: 05/29/2024
Date Signed: 05/29/2024 12:54:41 PM


Document Has Been Signed on 05/29/2024 12:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:AUTUMN ELDER CAREFACILITY NUMBER:
197610091
ADMINISTRATOR:OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:10055 SUNNYBRAE AVETELEPHONE:
(747) 237-0417
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: DATE:
05/29/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Myline Olivas, Administrator TIME COMPLETED:
01:10 PM
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An informal meeting was held today at the Woodland Hills Regional Office to discuss recent deficiencies and provide guidance to ensure future compliance.

Prior to the meeting, Licensee was given the chance to review the facility file.

Present at today's meeting were the following:
  • Myline Olivas - Administrator
  • Nichelle Gillyard - Licensing Program Manager (LPM)
  • Angela Panushkina - Licensing Program Analyst (LPA)


The informal conference process was explained to the Licensee. The Licensee was also informed that this Informal Meeting can lead to an Administrative Action Process.

BRIEF HISTORY: The facility Autum Elder Care has been in operation since licensure on 11/20/2020 From November 2020 to present, the Department received four (4) complaints, two of which were found Substantiated.

Continue on LIC809-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AUTUMN ELDER CARE
FACILITY NUMBER: 197610091
VISIT DATE: 05/29/2024
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LPM and LPA discussed reporting requirements. The Administrator has agreed to submit an incident report in regards to resident which was recently hospitalized. LPM clarified how the Plan of Correction days are counted. LPM will address Appeal in regards to Unusual Incident Reports. On 05/16/2024 an unannounced complaint visit was conducted by LPA Panushkina and the facility regarding the EVICTION PROCEDURES. LPA will continue and re-open an investigation to conduct interviews and if necessary, will issue an Amended report


Exit interview conducted and copy of this report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2